Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019 – 12/31/2019Molina Healthcare of Michigan, Inc.: Molina Silver 250 Plan Coverage for: Individual + Family | Plan Type: HMO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be providedseparately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit our website at MolinaMarketplace.com or call 1-888-560-4087. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary or call 1-800-318-2596 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible?

$5,350 Individual or $10,700/family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. Preventive care, Family Planning, Pediatric Vision, Hospice, Home Infusion (Admin only), Home Healthcare services, Dietician Services, Health Education Programs and Formulary Preventive Prescription Drugs are covered before you meet your deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

Yes. $400 Individual or $800/family for prescription drug coverage. (Tier 3 and 4 only)

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

What is the out-of-pocket limit for this plan?

For network providers $7,900 individual / $15,800 family; for out-of-network providers there is no coverage unless Prior Authorized by Molina Healthcare.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

Premiums, balance-billing charges, and health care this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

Will you pay less if you use a network provider?

Yes. See MolinaMarketplace.com or call 1-888-560-4087 for a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you getservices.

Do you need a referral to see a specialist?

No. You can see the specialist you choose without a referral.

10436079MIMP0519 OMB Control Numbers 1545-2229, 1210-0147, and 0938-116 Released on April 6, 2016 1 of 6

http://www.healthcare.gov/sbc-glossaryhttps://www.healthcare.gov/coverage/preventive-care-benefits/https://www.healthcare.gov/coverage/preventive-care-benefits/http://MolinaMarketplace.comhttp://MolinaMarketplace.com

prescription drug coverage is available at http://MolinaMarketpl ace.com/MIFormulary2 018.com

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay Common Medical Event

Services You May Need Limitations, Exceptions, & Other

Important Information Participating Provider (You will pay the least)

Non -Participating Provider

(You will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

$30 copay/office visit Not covered None

Specialist visit $75 copay/visit Not Covered Preauthorization may be required, or services not covered.

Preventive care/screening/ immunization

No charge Not Covered You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.

If you have a test

Diagnostic test (x-ray, blood work)

$40 copay/test for blood work $75 copay/test for x-rays

Not Covered None

Imaging (CT/PET scans, MRIs)

30% coinsurance after deductible

Not Covered Preauthorization is required or Imaging services are not covered

If you need drugs to treat your illness or

Tier 1 $20 copay/prescription (retail & mail order)

Not Covered

condition More information about

Tier 2 $60 copay/prescription (retail & mail order)

Not Covered

Tier 3 40% coinsurance after deductible

Not Covered

Tier 4 40% coinsurance after deductible

Not Covered

Covers up to a 30-day supply (retail subscription); 31-90 day supply (mail order prescription). Please note, cost sharing reduction for any prescription drugs obtained by You through the use of a discount card or coupon provided by a prescription drug manufacturer will not apply toward any Deductible, or the Annual Out-of-Pocket maximum under Your Plan. Coupons or any other form of third-party prescription drug cost sharing assistance will not apply toward any deductibles or annual out-of-pocket limits.

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery

30% coinsurance after deductible

Not Covered Preauthorization may be required, or services not covered.

Physician/surgeon fees 30% coinsurance after deductible

Not Covered Preauthorization may be required, or services not covered.

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http://MolinaMarketplace.com/MIFormulary2018.com

What You Will Pay Common Limitations, Exceptions, & Other Important Non -Participating Services You May Need Participating Provider Medical Event Information Provider (You will pay the least)

(You will pay the most) If you need Emergency room care 30% coinsurance after 30% coinsurance after Emergency room care copay does not apply, if immediate medical deductible/visit deductible /visit admitted to the hospital. attention Emergency medical 30% coinsurance 30% coinsurance

transportation

Urgent care $50 copay/visit Not Covered

Facility fee (e.g., hospital room) 30% coinsurance after Not Covered Preauthorization is required or services not deductible covered.

stay Not Covered Preauthorization may be required or services If you have a hospital

Physician/surgeon fees 30% coinsurance after not covered. deductible

If you need mental Outpatient services $30 copay/office visit Not Covered Preauthorization is required for inpatient care health, behavioral or services not covered. health, or substance Inpatient services 30% coinsurance after Not Covered

abuse services deductible

Not Covered Cost sharing does not apply to routine prenatal Office visits No Charge and post-natal care and certain preventive

Childbirth/delivery professional Not Covered services. Depending on the type of services, If you are pregnant 30% coinsurance after services coinsurance may apply. Maternity care may deductible include tests and services described Not Covered Childbirth/delivery facility

30% coinsurance after elsewhere in the SBC (i.e. ultrasound). services deductible

Home health care No Charge Not Covered 20 visits/ calendar year 30 visits/ calendar year Physical and Occupational Therapy (including osteopathic and chiropractic manipulation) (Combined benefit limit to 30 visits per calendar year). Speech Therapy (limited to 30 visits per Rehabilitation services $75 copay/visit Not Covered If you need help calendar year). Cardiac Rehabilitation and

recovering or have Pulmonary Rehabilitation (combined benefit other special health limit of 30 visits per calendar year). Breast needs Cancer Rehabilitation. Preauthorization may

be required or services not covered.

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and chiropractic manipulation) (Combined

Common Medical Event

Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important

Information Participating Provider (You will pay the least)

Non -Participating Provider

(You will pay the most) Habilitation services $75 copay/visit Not Covered 30 visits/ calendar year Physical and

Occupational Therapy (including osteopathic Skilled nursing care 30% coinsurance Not Covered 45 visits/calendar year. Preauthorization may

be required or services not covered.

Durable medical equipment 30% coinsurance Not Covered

Excludes vehicle modifications, home modifications, exercise, and bathroom equipment. Preauthorization may be required or services not covered.

Hospice services No Charge Not Covered 45 visits/calendar year

If your child needs dental or eye care

Children’s eye exam No Charge

Not covered Coverage limited to one exam/year.

Children’s glasses

No Charge

Not covered

Coverage limited to one pair of standard frames and prescription lenses/year. Limited to one pair of Contact Lenses per 12 months, in lieu of Rx glasses as Medically Necessary for specified medical conditions. Low Vision Optical Devices and Services. Subject to limitations, and Prior Auth applies.

Children’s dental check-up Not covered Not covered None

Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Cosmetic Surgery (unless medically necessary) Dental Care (Adult) Hearing aids

Infertility treatment Long-term care Non-emergency care when traveling outside theU.S

Private Duty Nursing Routine eye care (Adult) Routine Foot Care

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Bariatric Surgery Chiropractic Care (up to 30 visits per year if Weight Loss Programs

associated to Habilitation and Rehabilitationservices)

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Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Michigan Department of Insurance and Financial Services 1-877-999-6442. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: [insert applicable contact information from instructions].

Does this plan provide Minimum Essential Coverage? Yes.If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from therequirement that you have health coverage for that month.

Does this plan meet Minimum Value Standards? Yes.If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

[ ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

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http://www.HealthCare.gov

About these Coverage Examples:

Peg is Having a Baby (9 months of in network pre natal care and a

hospital delivery)

Managing Joe’s type 2 Diabetes (a year of routine i network care of a well-

controlled condition)

Mia’s Simple Fracture (in network emergency room visit and follow up

care)

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

The plan’s overall deductible $4,950 Specialist copayment $75 Hospital (facility) coinsurance 40% Other coinsurance 40%

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost $12,800

In this example, Peg would pay:

Cost Sharing

The plan’s overall deductible $4,950 Specialist copayment $75 Hospital (facility) coinsurance 40% Other coinsurance 40%

This EXAMPLE event includes services like: Primary care physician office visits (includingdisease education)Diagnostic tests (blood work)Prescription drugsDurable medical equipment (glucose meter)

Total Example Cost $7,400

In this example, Joe would pay:

Cost Sharing

The plan’s overall deductible $4,950 Specialist copayment $75 Hospital (facility) coinsurance 40% Other coinsurance 40%

This EXAMPLE event includes services like: Emergency room care (including medical supplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)

Total Example Cost $1,900

In this example, Mia would pay:

Cost Sharing

What isn’t covered What isn’t covered What isn’t coveredLimits or exclusions $60 The total Peg would pay is $7,100

Limits or exclusions $60 The total Joe would pay is $3,400

Limits or exclusions $0 The total Mia would pay is $900

Deductibles $2,100 Deductibles* $1,000 Deductibles* $40 Copayments $400 Copayments $1,600 Copayments $600 Coinsurance $4,500 Coinsurance $700 Coinsurance $300

*Note: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?” row above.

The plan would be responsible for the other costs of these EXAMPLE covered services. 6 of 6

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Non-Discrimination Notification Molina Healthcare

Molina Healthcare (Molina) complies with all Federal civil rights laws that relate to healthcare services. Molina offers healthcare services to all members and does not discriminate based on race, color, national origin, age, disability, or sex. Molina also complies with applicable state laws and does not discriminate on the basis of creed, gender, gender expression or identity, sexual orientation, marital status, religion, honorably discharged veteran or military status, or the use of a trained dog guide or service animal by a person with a disability.

To help you talk with us, Molina provides services free of charge: • Aids and services to people with disabilities

o Skilled sign language interpreters o Written material in other formats (large print, audio, accessible electronic formats, Braille)

• Language services to people who speak another language or have limited English skills o Skilled interpreters o Written material translated in your language

If you need these services, contact Molina Member Services. The number is on the back of your Member ID card (TTY: 711).

If you think that Molina failed to provide these services or discriminated based on your race, color, national origin, age, disability, or sex, you can file a complaint. You can file a complaint in person, by mail, fax, or email. If you need help writing your complaint, we will help you. Call our Civil Rights Coordinator at (866) 606-3889, or TTY: 711.

Mail your complaint to: Civil Rights Coordinator, 200 Oceangate, Long Beach, CA 90802

You can also email your complaint to civil.rights@molinahealthcare.com. Or, fax your complaint.

CA (844) 479-5337 MI FAX Numbers for Molina Civil Rights Coordinator

(248) 925-1799 OH (866) 713-1891 UT (866) 472-0589 WI (888) 560-2043 FL (877) 508-5748 NM (505) 342-0583 TX (877) 816-6416 WA (800) 816-3778

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. You can mail it to: U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201

You can also send it to a website through the Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.

If you need help, call (800) 368-1019; TTY (800) 537-7697.

5941240MP0417

mailto:civil.rights@molinahealthcare.comhttp://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf

You have the right to get this information in a different format, such as audio, Braille, or large font due to special needs or in your language at no additional cost.

Usted tiene derecho a recibir esta información en un formato distinto, como audio, braille, o letra grande, debido a necesidades especiales; o en su idioma sin costo adicional.

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call Member Services. The number is on the back of your Member ID card. (English)

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame a Servicios para Miembros. El número de teléfono está al reverso de su tarjeta de identificación del miembro. (Spanish)

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電會員服務。電話號碼載於您的會員證背面。 (Chinese)

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Hãy gọi Dịch vụ Thành viên. Số điện thoại có trên mặt sau thẻ ID Thành viên của bạn. (Vietnamese)

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa Mga Serbisyo sa Miyembro. Makikita ang numero sa likod ng iyong ID card ng Miyembro. (Tagalog)

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 회원 서비스로 전화하십시오. 전화번호는 회원 ID

카드 뒷면에 있습니다. (Korean)

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele Sèvis Manm. W ap jwenn nimewo a sou do kat idantifikasyon manm ou a. (French Creole)

ВНИМАНИЕ: Если вы говорите на русском языке, вы можете бесплатно воспользоваться услугами переводчика. Позвоните в Отдел обслуживания участников. Номер телефона указан на обратной стороне вашей ID-карты участника. (Russian) ՈՒՇԱԴՐՈՒԹՅՈՒՆ․ Եթե դուք խոսում եք հայերեն, կարող եք անվճար օգտվել լեզվի օժանդակ ծառայություններից։ Զանգահարե՛ք Հաճախորդների սպասարկման բաժին։ Հեռախոսի համարը նշված է ձեր Անդամակցության նույնականացման քարտի ետևի մասում։ (Armenian)

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。

会員サービスまでお電話ください。電話番号は会員IDカードの裏面に記載されております。 (Japanese)

bic)Ara(.بال او ضعلاف ير عتة قاطبف لخد وجوما ذهف تاهلام قرو .ءاضعلأات امدخم سقبل صتا.ك ل، اً◌ناجم، ةيوغللا ة دعاسملات امدخح اتت، ةيبرعلاة غللام دختستت نكا ذإ:ه يبنت كة صخ

جردا مشت يوضعی ياسانشت راکت شپیورن فلتهرامش .ديريگبس امتا ضعات امدخاب.دنتسها مشس رتسدر ده نيزهن ودب،ینابزک مکت امدخ، دينکیمت بحصی سرافن ابزه بر گا؛هجوت(Farsi)تساه دش .

ਿਧਆਨ ਿਧਓ: ਜ◌ੇ ੰ ੋ ੇ ੋ ੁ ੇ ਲਈ ਭਾਸ਼ਾ ਸਹਾਇਤਾ ਸੇ ੁ ਬਰ ਸਰਧਵਧਸਜ (Member ਕਰ ਤਸ ਪ◌ਜ◌ਾਬ◌ੀ ਬ◌ਲਿ◌◌ ਹ◌, ਤ ਤਹਾਡ◌ ਵਾਵ ਮਫ਼ਤ ਉਪਲਬਿ◌ ਹਨ। ਮ

Services) ਨ◌ੰ ਫੋ ੋ ੰ ਬਰ ਤੁ ੇ Member ID (ਮਬਰ ਆਈ.ਡੀ.) ਕਾਰਡ ਿ◌◌ੇ ਧਪਛਲ ਪਾਸੇ ਹ। (Punjabi) ਨ ਕਰ।ਨ ਹਾਡ ੇ ੈ

Molina Marketplace, Created 03.14.17

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Wenden Sie sich telefonisch an dieMitgliederbetreuungen. Die Nummer finden Sie auf der Rückseite Ihrer Mitgliedskarte. (German)

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez les Services aux membres. Lenuméro figure au dos de votre carte de membre. (French)

LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Cov npawb xov tooj nyob tom qab ntawm koj daim npavtswv cuab. (Hmong)

Molina Marketplace, Created 03.14.17

Molina Healthcare of Michigan, Inc.: Molina Silver 250 PlanImportant QuestionsCommon Medical EventExcluded Services & Other Covered Services:Your Rights to Continue Coverage:Your Grievance and Appeals Rights:Does this plan provide Minimum Essential Coverage?Does this plan meet Minimum Value Standards?

About these Coverage Examples:Non-Discrimination Notification Molina Healthcare